Anorectal Dz Flashcards
Anal Fissures
- definition
- causes
- most commonly found where?
- clinical presentation
- PE
Def: painful linear tear or crack in the distal anal canal.
Causes:
- trauma to anal canal
- defication
- straining
- constipation
- Most commonly occur in the 12 or 6 o clock area.
- if tear found in 3 or 9 oclock think crohns.
- Clinical Presentation:
- C/O severe tearing pain during defication
- mild hematochezia (blood on stool or toilet paper
PE: confirmed by visual insepction of the anus
- acute: crack in the epithelium
- chronic: fibrosis and development of a skin tag.
Anal Fissure:
-Tx
First line: fiber supplements, stool softeners, and sitz baths
Second line:
- 0.4% nitroglycerin ointment BID for 6-8wks (decreases spasm, helps increase blood flow to the area)
- botulinum toxin (inject into anal sphincter)
- Internal anal sphincterotomy
Perianal abscess
- what is this?
- MC type?
- causes
- risk factors
- presentation
What: anal glands at the base of the rectum become infected. Appears as a boil like swelling near the anus.
MC type: Perianal abscess
Cause: anal fissures, anal fistulas, hemorrhoids, blocked anal glands
Risk factors:
- colitis
- inflamm bowel dz
- DM2
- PID
Presentation:
- constant throbbing pain that is worse when sitting
- swelling and redness around the anus
- painful bowel movements
- discharge of pus around the anus
- deeper abscesses:
- -fever
- -chills
- -malaise
Perianal abscess:
- lab studies
- tx
Labs: wound cultures and I&D
Tx: I&D
- packing and return in 24hrs
- sitz bath 3x/day and after bowel movements
- f/u in 2-3wks for wound eval.
- **DONT give ABX.
Anal Fistula:
- aka
- results from what?
- etiology
- clinical presentation
- PE
- Tx
aka: fistula-in-ano
results from : previous or current anal abscess
Etiology:
- anorectal abscess
- crohns
- radiation proctitis
Presentation:
- hx of drained abscess
- anorectal pain
- purulent drainage and irritation from the skin
PE:
- identification of the external opening that drains pus, blood, or stool
- DRE may express pus or stool from the opening
Tx:
- fistulotomy
- complex fistulas:
- -fibrin glue
- -fistula plug
Pruritis Ani
- what is this?
- causes
- PE
- Tx
- Prevention
What:
- perianal itching or discomfort
- itch-scratch-itch cycle; skin becomes excoriated and 2ndry infections occur
Causes:
- idiopathic
- hygiene related
- fistulas/fissures
- fecal incontinence
- parasites
- lichens sclerosis
PE:
- inspection of the area may reveal anal excoriations and erythema
- hygiene issues
- chronic issues show thickened or leathery skin
- anoscopy
Tx:
- treat underlying cause
- avoid spicy acidic foods
- after BM clean with unscented wipes
- place gauze or cotton ball next to anal opening
- talcum powder
- use zinc oxide or hydrocortisone ointment.
Rectal Prolapse:
- aka
- what is this?
- MC gender and age?
- sx
- causes
- dx
- tx
aka: rectal procidentia
What: painless protrusion of the rectum through the anus
MC in older adults w/ hx of constipation and weak pelvic floor muscles.
More common in women over 50*
Sx:
- feeling a bulge or apperance of reddish colored mass that extends outside the anus
- pain in the anus or rectum?
- leakage of blood or stool
Cause:
- chronic constipation of diarrhea
- straining during BM
- weakness of anal sphincter
- damage to nerves
Dx
- anal EMG
- anal monometry
- anal ultrasound
- colonoscopy
- proctosigmoidoscopy
Tx
- 1st use stool softeners and pushing the fallen tissue back up into the anus by hand
- surgery: abdominal repair, rectal repair
- Recovery: 3-5 days w/ complete recovery in 3mo
Pilonidal Cyst
- what is this?
- cause
- MC in what age and gender?
- risk factors
- clinical presentation
- tx
What: cyst near the natal cleft that often contains hair or skin debris
Cause:
-when hair punctures the skin and becomes imbedded
MC in hair young men
Risk:
- sitting for long periods of time
- obesity
- local trauma/irritation
Clinical presentation:
- pain
- erythema and swelling of the skin
- drainage of foul smelling pus or blood from opening of the skin
Tx:
- 1st I&D cyst; may need to leave open or pack
- if recurrent will need surgical cyst removal
- abx if worried about cellulitis; 1st gen cephalosporin(cefazolin) plus flagyl
Hemorrhoids
- what is this?
- types
- classification
- cause
What: dilated veins of the hemorrhoidal plexus in the lower rectum
Types:
-external(below adente line) and internal
Classification:
- Grade 1: hemorrhoids do not prolapse
- grade 2: hemorrhoids prolapse on defecation and reduce spontaneously (slinky)
- Grade 3: hemorrhoids prolapse on defication and must be reduced manually
- Grade 4: hemorrhoids are prolapse and cannot be reduced manually
Cause:
- pregnancy
- frequent heavy lifting
- repeated straining during defication
- constipation
Hemorrhoids:
- clinical presentation
- dx
- tx
Presentation:
- asymptomatic
- external: painful and purplish swelling, rarely ulcerate and cause minor bleeding, swelling lasting a few weeks, itchiness around anus, may become thrombosed.
- internal: bleeding after defication, blood on stool or TP, mucous and fecal incontinence, itchiness, strangulated hemorrhoids may be very painful.
Dx:
- Anoscopy
- sigmoidoscopy or colonoscopy
Tx:
- stool softeners/fiber
- sitz baths after BM
- anesthetic ointments
- 2nd line is banding if conservative tx is unsuccessful
- 3rd line: surgical removal
Hernias
- what is this?
- types
- MC type in adults
What:
- a protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it
- normally harmless
- if strangulated the hernia becomes medical emergency
Types:
- inguinal (direct and indirect)
- umbillical
- incisional/ventral
- epigastric
- femoral
- spigelian
MC type in adults is inguinal hernia
Inguinal hernia
- MC in which gender?
- what is this?
- risk factors?
MC in men
What: weak area in the inguinal canal where the spermatic cord or round ligament exits the abdoment.
Risk factors:
- hx of hernia or repair
- chronic cough or constipation
- abdominal wall injry
- smoking
What are the two types of inguinal hernias? Which type is most common?
Describe each.
Indirect and Direct.
Indirect is MC.
IndirecT: hernia protudes throught the internal inguinal ring, hernia sac is located lateral to the inferior epigastric artery. sometimes the hernia will protrude into the scrotum. (some bowel contents can go into the scrotum and you can hear bowel sounds)
Direct: protrude medial to the inferior epigastric vessels within the hesselbachs triangle. rarely protrude into the scrotum
What are the barriers of the Hesselbach triangle?
Laterally: inferior epigastric artery
Medially: rectus abdominus
Inferiorly: inguinal ligament
Femoral Hernia:
- located where?
- MC in which gender?
- high chance of what?
Located: inferior to the inguinal ligament and protrudes through the femoral ring
MC in women
High chance of strangulation
Inguinal Hernia:
- clinical presentation
- PE
- Dx
- Tx
Presentation::
- painless bulge in the groin or scrotum
- groin discomfort or pain
- swelilng of tugging in the groin
- sudden pain, n/v you would need to be concerned with strangulated hernia
PE:
- bulge in groin is MC
- pt stand and ask them to cough or valsalva
- reducible or irreducible
- Strangulated: irreducible, painful to palpation, N/V. may appear ill w/ or w/o fever.
- if you cant reduce it then they need to be referred to general surgery.
Dx:
- hx and exam
- if not apparent then initial study is groin ultrasound
- CT/MRI
Tx:
- non-surgical: watchful wiating, or TRUSS
- Surgical: open repair, laparoscopic repair. Use mesh or keyhole mesh.
Umbilical Hernia
- what is this?
- MC in who?
- cause
- presentation
- tx
What: outward bulging of the lining of the abd or abdominal organs around the belly button
MC in infants
Cause:
- muscle through which the umbilical cord passes doesnt close completely after birth
- obesity
- multiple pregnancies
- fluid in abd cavity (ascites)
- previous abd surgery
Presentation:
- soft swelling or bulge near the umbilicus
- more noticeable when baby cries, coughs, strains
- adults cause abd discomfort, bulgind with strain or coughing
- Can be strangulated
Tx: surgery +/- mesh
Incisional/ventral hernia
-cause
Cause: abd surgery causes a flaw in the abd wall that must heal on its own, this weakness may lead to hernia
-iatrogenic
Epigastric hernia
- What is this?
- risk factors
What: hernia that develops in the epigastrum between the breast bone and the belly button.
Risk factors:
-obesity and pregnancy
Spigalian Hernia:
- aka
- what is this?
- MC occur where?
- sx
- dx
- tx
aka: lateral/ventral hernia
What: hernia through the spigelian fascia, high chance of strangulation
MC occur on the right side of the rectus abdominus
Sx:
-intermittent mass, localized pain or N/V
Dx:
-US
Tx:
-surgery is treatment of choice
Gastrointestingal acute abd
-what are the 4 types of pain experienced with this?
Visceral: from abd viscera, respond to sensations of distention and muscular contraction. Pain is vague, dull, nauseating
Innervated by autonomic nerves
Somatic Pain:
-from parietal peritoneum, respond to irritation from infection, chemical, and inflamm process, pain is shartp and well localized. Innervated by somatic nerves
Reffered pain:
-pain perceived distant from its source
Peritonitis:
- inflamm of peritoneal cavity
- most serious cause is perforation of GI tract
- causes fluid shift into the peritoneal cavity and bowel, leasds to severe dehydration and electrolyte problems.
Acute Abd: Appendicitis
-sx
Sx: anorexia, and vague periumbilical discomfort that develops into RLQ pain
urinary sx and diarrhea
Acute Abd: Biliary dz
-sx
sx: acute cholecystitis c/o RUQ or epigastric pain
Pain may radiate to shoulder or back
-n/v and anorexia
Murphys sign present: positive for cholecystitis. Place hand mid clavicular and inferior to costal margin. Ask pt to breath out and upon inspiration push gently down into abd, if positive pt should wince and you should feel gallbladder. Must do this on the left side w/o eliciting a rxn for murphy sign to be positive.
Acute Abd: Pancreatitis
-sx
Sx: pain is steady in upper abd, bandlike radiation to the back is common
- n/v comm
- paint often reaches maximum intensity within 10-20minutes
